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Circadian Rhythm Sleep Disorders

Summary

Circadian rhythm sleep disorders (CRSD), a family of sleep disorders, affect (among other bodily processes) the timing of sleep. People with circadian rhythm sleep disorders are unable to go to sleep and awaken at the times commonly required for work and school as well as social needs.

They are generally able to get enough sleep if allowed to sleep and wake at the times dictated by their "body clocks". The quality of their sleep is usually normal unless they also have another sleep disorder.

Summary

Circadian rhythm sleep disorders (CRSD), a family of sleep disorders, affect (among other bodily processes) the timing of sleep. People with circadian rhythm sleep disorders are unable to go to sleep and awaken at the times commonly required for work and school as well as social needs.

They are generally able to get enough sleep if allowed to sleep and wake at the times dictated by their “body clocks”. The quality of their sleep is usually normal unless they also have another sleep disorder.

Introduction

Humans, like most living organisms, have various biological rhythms. Circadian rhythms, often referred to as the body clock or the biological clock, control processes that re-occur daily, e.g. body temperature,alertness, and hormone secretion as well as sleep timing. Due to the circadian clock, sleepiness does not continuously increase throughout the day; a person’s desire and ability to fall asleep is influenced both by the length of time since the person woke from an adequate sleep and by internal circadian rhythms. Thus, a person’s body is ready for sleep and for wakefulness at relatively specific times of the day.

Sleep researcher Yaron Dagan states that “[t]hese disorders can lead to harmful psychological and functional difficulties and are often misdiagnosed and incorrectly treated due to the fact that doctors are unaware of their existence”.[1]

Types of circadian rhythm sleep disorders

Extrinsic type

One of these disorders is extrinsic (from Latin extrinsecus, from without, on the outside) or circumstantial:

Shift work sleep disorder, which affects people who work nights or rotating shifts.
Formerly,[2] jet lag, too, was classified as an extrinsic type circadian rhythm disorder.

Intrinsic type

Four of them are intrinsic (from Latin intrinsecus, on the inside, inwardly), “built-in”:

Delayed sleep phase disorder (DSPD), aka delayed sleep phase syndrome (DSPS), characterized by a much later than normal timing of sleep onset and offset and a period of peak alertness in the middle of the night

Irregular sleep–wake rhythm, which presents as sleeping at very irregular times, and usually more than twice per day (waking frequently during the night and taking naps during the day) but with total time asleep typical for the person’s age

Non-24-hour sleep–wake disorder (non-24, aka hypernychthemeral syndrome), in which the affected individual’s sleep occurs later and later each day, with the period of peak alertness also continuously moving around the clock from day to day.

Normal circadian rhythms

Typical features of a normal circadian rhythm, including a bedtime of 22:00.From Wikipedia entry

Among people with healthy circadian clocks, there is a continuum ofchronotypes from “larks”, “morning people”, who prefer to sleep and wake early, to “owls”, “evening people” or “night people”, who prefer to sleep late at night and wake at late times. Whether they are larks or owls, people with normal circadian systems:

can wake in time for what they need to do in the morning, and fall asleep at night in time to get enough sleep before having to get up.

can sleep and wake up at the same time every day, if they want to.

will, after starting a new routine that requires their getting up earlier than usual, start to fall asleep at night earlier within a few days. For example, someone used to sleeping at 1 a.m. and waking up at 9 a.m. begins a new job on a Monday, and must get up at 6 a.m. to get ready for work. By the following Friday, the person has begun to fall asleep at around 10 p.m., and can wake up at 6 a.m. feeling well-rested. This adaptation to earlier sleep/wake times is known as “advancing the sleep phase.” Healthy people can advance their sleep phase by about one hour each day.

Researchers have placed volunteers in caves or special apartments for several weeks without clocks or other time cues. Without time cues, the volunteers tended to go to bed an hour later and to get up about an hour later each day. These experiments appeared to demonstrate that the “free-running” circadian rhythm in humans was about 25 hours long. However, these volunteers were allowed to control artificial lighting and the light in the evening caused a phase delay. More recent research shows that adults of all ages free-run at an average of 24 hours and 11 minutes. To maintain a 24-hour day/night cycle, the biological clock needs regular environmental time cues or zeitgebers, e.g., sunrise, sunset, and daily routine. Time cues keep the normal human circadian clock aligned with the rest of the world.[3]

Circadian rhythm abnormalities

Non-24-hour sleep–wake disorder and other persistent circadian rhythm sleep disorders are believed to be caused by an inadequate ability to reset the sleep/wake cycle in response to environmental time cues. These individuals’ circadian clocks might have an unusually long cycle, and/or might not be sensitive enough to time cues. People with DSPD (Delayed sleep phase disorder), more common than Non-24, do entrain to nature’s 24 hours, but are unable to sleep and awaken at socially preferred times, sleeping instead, for example, from 4 a.m. to noon. According to doctors Cataletto and Hertz at WebMD, “Altered or disrupted sensitivity to zeitgebers is probably the most common cause of circadian rhythm disorder.”[4]

Circadian rhythm abnormalities are also extremely commonly co-morbid with ADHD, especially in the form of sleep initiation insomnia. These have been genetically linked by findings of polymorphism in genes in common between those apparently involved in ADHD and those involved in thecircadian rhythm[5][6] and a high proportion of DSPD among those with ADHD,[7][8] however no specific or further cause-effect relationship has been proven.

As of October 1, 2005, the diagnostic codes for circadian rhythm sleep disorders were changed from the 307-group to the 327-group in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). The DSM updated to agree with the International Classification of Diseases (ICD-9). The new codes reflect the moving of these disorders from the Mental Disorders section to the Neurological section in the ICD.[9]

Treatment for circadian rhythm sleep disorders

Possible treatments for circadian rhythm sleep disorders include:

Behavior therapy or advice about sleep hygiene where the patient is told to avoid naps, caffeine, and other stimulants. They are also told to not be in bed for anything besides sleep and sex.[10]

Bright light therapy is used to advance or delay sleep, depending on how (in which direction) the circadian rhythm needs to be shifted. Patients are exposed to high-intensity light from the sun, a light box (up to 10,000 lux) or wearable light therapy device (up to 500 lux) for a duration of 30–60 minutes daily, the time of day depending on whether an advance or a delay is required.[11]

Dark therapy, for example the use of blue-blocking goggles, is used to block blue- and bluegreen wavelength light from reaching the eye during evening hours so that the production of melatonin is not decreased or eliminated.[12]

Medications such as melatonin and modafinil (Provigil), or other short term sleep aids or wake-promoting agents can be beneficial; the former is a natural neurohormone responsible partly and in tiny amounts for the human body clock. The melatonin agonist Tasimelteon, trade name Hetlioz, has been approved in the USA solely for the treatment of non-24-hour sleep–wake disorder in totally blind people.[13]